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Health Care Transactions

Health Care Transactions. ANSI ASC X12N Insurance Sub-Committee Task Group 3 Business Transaction Coordination and Modeling Work Group 2 Health Care Modeling. Give an overview of the “big picture” of HIPAA transactions what each does how they interact with each other.

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Health Care Transactions

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  1. Health Care Transactions ANSI ASC X12N Insurance Sub-Committee Task Group 3 Business Transaction Coordination and Modeling Work Group 2 Health Care Modeling

  2. Give an overview of the “big picture” of HIPAA transactions what each does how they interact with each other Purpose of Presentation

  3. Patient information Subscriber Patient information Subscriber information Premium Payment Premium Payment Prior Authorization/ Referral/CMN Prior Authorization/ Referral/CMN Claim/ Encounter Claim/ Encounter Claim Status Claim Status Sponsor Payer Provider Eligibility Inquiry 270 Enrollment 834 Eligibility Response 271 Premium Payment 820 Request for Review 278 Review Response 278 HIPAA Transactions ASC X12N TG3 GW2 Summary of HIPAA Transactions Claim/Encounter 837 COB Claim Remittance Advice 835 Request Additional Information 277 Attachments 275/HL7 Status Inquiry 276 Status Response 277

  4. HIPAA Impact to Providers “All health care providers who elect to conduct these specific transactions electronically must conduct them according to the standards as well. Health care providers may also contract with a clearinghouse to conduct standard transactions for them.” * * Department of Health and Human Services - Most Frequently asked questions (http://aspe.hhs.gov/admnsimp/)

  5. HIPAA Impact to Health Plans “Health plans may not refuse to accept standard transactions submitted electronically (on their own or through clearinghouses). Further, health plans may not delay payment because the transactions are submitted electronically in compliance with the standards.” * * Department of Health and Human Services - Most Frequently asked questions (http://aspe.hhs.gov/admnsimp/)

  6. Data Content There are two aspects of data content standardization addressed in the HIPAA rules: • standardization of data elements, including their formats and definition, and • standardization of the code sets or values that can appear in selected data elements. • ICD Diagnosis Codes • CPT Procedure Codes • HCPCS Procedure Codes • CDT Procedure Codes • NDC Drug Codes • Others

  7. Modifications to Transactions “Once we publish the final rule in the Federal Register and it is effective, there will be no additional data element or record/segment content modifications in any of the transactions for at least one year.” * * Department of Health and Human Services - Most Frequently asked questions (http://aspe.hhs.gov/admnsimp/)

  8. The MOU addresses future maintenance of the data content within the HIPAA transactions. It is the understanding of thecombined efforts of HHS - Health and Human Services X12N NUCC - National Uniform Claim Committee NUBC - National Uniform Billing Committee ADA - American Dental Association HL7 - Health Level 7 NCPDP Memorandum of Understanding (MOU)

  9. Provider Sponsor 270 Eligibility Request 834 Enrollment 271 Eligibility Response Health Plan Subscriber/Patient Information

  10. 834 Enrollment Sponsor Health Plan 820 Premium Payment Premium Information

  11. Provider 278 Request for Authorization 278 Response to Authorization Health Plan Health Service Review (Authorization)

  12. 837 Claim/Encounter Submission Provider 275 Attachment Health Plan 835 Remittance Advice Claim / Encounter Submission w/ an Attachment

  13. 837 Claim/Encounter Submission Provider Health Plan 277 Request for Additional Information 275/HL7 Attachment 835 Remittance Advice Claim / Encounter SubmissionPayer requests additional information

  14. 837 1 - Claim/Encounter Submission Provider 835 1 - Remittance Advice Primary Health Plan Secondary Health Plan 837 2 - COB Claim/Encounter Submission 835 2 - Remittance Advice Coordination of Benefits Claim / Encounter SubmissionProvider-to-Payer Model

  15. 837 1 - Claim/Encounter Submission 837 2 - Claim/Encounter Submission with 835 Information Provider Secondary Health Plan Primary Health Plan 835 2 - Remittance Advice 835 1 - Remittance Advice Coordination of Benefits Claim / Encounter Submission Payer-to-Payer Model

  16. Provider 276 Claim Status Inquiry Health Plan 277 Claim Status Response Claim Status (Solicited)

  17. This presentation has been developed by X12N (Insurance) Task Group 3 (Modeling) Work Group 2 (Health Care Insurance). For further information contact a Co-Chair of this group, listed on the DISA web site, http://www.disa.org For Further Information

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